National Fire Fighter Near-Miss Reporting System
January-Attic Fires
Prepared by Battalion Chief G. O. Lyon (Ret.),
Arlington County Fire Department (VA)
Part 1: Introduction
An attic for the purpose of this discussion is defined
as the unfinished space directly between the ceiling of
the top floor and the pitched roof of a building or
house. Attics are known for being awkwardly shaped with
exposed rafters, difficult to access, and often used for
storage. Attic fires are normally a result of a
defective chimney, faulty electrical wiring, lighting,
or fire extending vertically from below. These fires are
often not discovered until smoke and flames are visible
from outside, resulting in well advanced fires. Attic
fires present unique challenges and hazards to
firefighters. Listed below are some of the dangers faced
by firefighters attempting to extinguish an attic fire
and various safety precautions that should be taken:
• Unprotected structural members, possibly lightweight
trusses.
o
If the roof is known or suspected to be of lightweight
truss construction, Command should be notified and a
risk benefit analysis conducted.
o
If lightweight trusses are suspected, strong
consideration should be given to allowing the roof to
self ventilate or firefighters should be required to
work from a tower ladder bucket or aerial ladder.
• Heavy fire loading, extreme heat build up, and rapid
fire spread.
o
The attack should be initiated from the floor below a
minimum 1 ¾ line.
o
Lines should be deployed and ceilings opened in areas
exposed to horizontal fire spread.
• Storage, HVAC units, and water heaters are often
located in unfinished attics and add a significant load
to the ceiling joists. False dormers add a concentrated
load to the roof. Both can accelerate a ceiling and/or
roof collapse.
o
Firefighters should be alert to the signs of collapse.
• Access to the attic from the top floor is normally
limited to a small scuttle located in a closet, a
“pull-down” stairs in a hall, or a constructed stair in
older buildings.
o
Firefighters should not enter the attic area for fire
attack.
o
Crews may use an attic scuttle if readily available, or
poke a small hole for placement of the nozzle. Flow a
fog pattern for several seconds. The fire should darken
down due to the steam conversion and expansion. Avoid
flowing the nozzle too long, or the ceiling may become
saturated and collapse into the living area. Extensive
ceiling removal may still be required for complete
extinguishment.
o
Pull-down attic stairs shall not be used when fire is in
the attic. These stairs are typically rated to only 250
pounds and their integrity is questionable due to
exposure to fire. A F.D. attic ladder should be used,
however in most cases the nozzle can be advanced through
the opening without ladders.
o
If
a constructed stairs is available it may be used to
advance the nozzle into the attic area.
•
There may be no flooring or flooring that covers only
the center area of the ceiling joists.
o
Firefighters should not enter the attic area for fire
attack.
•
There is a possibility of a backdraft occurring when
ceilings are opened without proper ventilation.
o
Fire attack should be coordinated with ventilation of
the roof or a gable vent
•
Fire and smoke conditions on the top floor can change
rapidly when the ceiling is opened. The top floor
ceiling or roof may suddenly collapse without warning.
Either situation may cut off your primary escape route.
o
A
charged hoseline should be in position before the
ceiling or any other opening is made.
o
The
firefighter opening the ceiling should work between the
door and the area to be opened.
o
The
top floor windows should be opened and ladders should be
thrown to the top floor.
o
The
company officer, Division Supervisor or a designated
Safety Officer should be constantly monitoring the
surroundings for changing conditions.
•
When the fire involves the attic the firefighters
ventilating the roof are operating directly over the
fire.
o
A
risk benefit analysis needs to be conducted.
o
What will open the roof on this fire accomplish and is
it worth the risk? It may be better to let it self
ventilate or use an alternate means of ventilation.
o
To
avoid having your escape route cut off by fire and smoke
a second remote escape route should be provided and all
members must be aware of the location.
• A
fire in the attic may have extended from a yet
undetected fire located on a lower floor of the
building.
o
Command should assign units to check the floors below to
insure that there is not a fire burning unchecked below
the units operating on the attic fire.
The
near-miss case study that follows involves a ceiling and
roof collapse and the resulting Mayday call. It had a
good outcome and disaster was averted because some of
the following good practices were employed:
• A
charged back-up line was in place;
• A
RIT was established and ready to respond;
• A
Division Chief was assigned to the top floor;
•
An emergency evacuation SOG was in place and activated
by the Division Commander following the collapse of the
ceiling and roof;
•
The RIT had a hoseline and was able to control the fire
on the first floor that had cut off the escape route of
the crew that was attempting to exit the top floor; and
•
The IC conducted an accountability check following the
emergency evacuation.
Part 2: Case Study 06-0000042
This was a residential house fire of a two story house
with the attic heavily involved upon arrival of the
first unit on scene. Command was established and
interior attack ordered. The first unit advanced a 1 ¾”
to the attic and the second unit advanced a 2 ½” to the
attic. Fire attack was underway when the roof and
ceiling system failed plummeting two firefighters to the
second floor. Debris fell on top of the fallen
firefighters and the crews operating on the second
floor. This was lathe and plaster walls and ceilings.
Visibility went to zero after the collapse, and we did
not know that two firefighter were down. After the
Division commander called for a report of any injuries
the two injured firefighters were found and a may-day
was called over the radio by the Division Commander.
Command was told that the crews operating on the second
floor would be able to remove the two injured
firefighters with man-power already located on the
second floor, and that the RIT team could hold its
position. Command was also instructed by the Division
Commander to order an evacuation of the structure. Crews
removed the injured Firefighters and another sweep of
the area was made to ensure no other firefighters were
down. As the Division Commander and the few firefighters
that stayed to search descended the stairwell, a
fireball rolled up the stairs causing the remaining
personnel to retreat up the stairs. At this time, there
was no way for the trapped crew to exit the building.
The RIT team was told that personnel were unable to exit
the structure because of the fire on the first floor.
The fire came from a hot tub located on the exterior
deck that became engulf from the falling roof system
igniting the foam cover and fiberglass. The hot tub was
located just outside a window that was at the bottom of
the stairs. The RIT team extinguished the fire allowing
the trapped crews to exit the structure. After all
personnel exited the structure, a personnel
accountability report was requested of all units. One
firefighter that had to retreat to the second floor was
initially unaccounted for. This was because he exited
the second floor onto a balcony that led to the fenced
back yard and it took an extra minute for him to make
his way back to his company. The two firefighters were
treated for 1st and 2nd degree burns.
Lessons Learned
Lessons / Suggestions learned from this incident: 1.
Command must maintain control of the incident not
allowing everybody to go to the seat of the fire. Slow
crews down and do not allow them just to run in. 2.
Company Officers must assign positions on the hose-line
to allow proper advancement. 3. When crews are operating
on upper levels, provide secondary means of egress. This
can be accomplished by the RIT team throwing ground
ladders and notifying command via the radio that a
ladder has been place in the X Division for egress. By
stating this on the radio, crews operating inside will
know of its location. 4. Even though the fire maybe
located on the upper level, provide a protection line
for the stairwell. 5. If trapped, maintain crew
integrity, do not leave the crew to solo on your own to
find a way out. Nobody will know your location if you're
unaccounted for.
Discussion Questions
After reviewing this case study consider the following
as they apply to you, your crew and your Department.
1.
Does your Department have a building fire SOP/SOG and
does it specifically address attic fires? Does it
prohibit firefighters from actually entering an attic
for fire attack?
2.
Does your Department routinely provide at least 2 escape
routes from upper floors?
3.
Does your Department have a specific SOP/SOG that deals
with emergency evacuation? Does it include more than one
means of notification and does it include a personnel
accountability check? Are all companies, including
mutual aid companies, well trained and familiar with it?
4.
Even though there is no indication that this roof was
constructed of lightweight trusses, do you know how to
identify lightweight truss construction? Does your
Department have a SOP/SOG concerning operating on
lightweight truss roofs?
5.
What critical size up information would you require to
make your risk/benefit analysis to determine if the risk
out weights the benefits for firefighters operating
below a “heavily” involved attic or on the roof above
it?
6.
Is an RIT automatically assigned on the first alarm and
is there a SOP/SOG that deals with their duties? If so,
are all companies, including mutual aid companies, well
trained and familiar with it?
7.
Is the RIT encouraged to take proactive action as they
deem necessary to try to prevent a “Mayday” situation
(i.e. - putting up ladders, opening secondary means of
egress, etc.) while conducting their RIT size-up?
8.
Does your RIT trained to plan where to acquire and
deploy protective hose-line if needed for rescue? In
this case as in many others a protective hoseline may be
critical to their mission.
9.
What role did the elements of Crew Resource Management
(Communications, Situational Awareness, Decision Making,
Teamwork, Task Allocation, and Debrief)) play this
incident?
10.
What specific elements of CRM would you apply to a
similar incident within your role (firefighter, Company
Officer, Incident Commander) in your Department? What,
if any, external (physical) or internal (prejudice,
opinions, attitudes, stress) barriers exist that inhibit
the use of CRM in your Department?
11.
What did you learn from this case study that will help
you to avoid a similar near miss?
Part 3: Crew Resource Management Discussion
•
Communication – interruptions in the
communication flow result in messages and orders being
misinterpreted, not properly conveyed, completely missed
or not carried out
o
The
communications (Mayday request, RIT canceled, evacuation
order, 2nd
Mayday request) between the Division Chief
and the IC were clearly understood despite the
distractions of the collapse, downed and missing
firefighters, and the fact that “visibility went to
zero” following the collapse.
o
The
orders were understood and followed without question or
hesitation.
o
The
IC conducted an accountability check following the
evacuation.
o
The
firefighter that became separated from his crew during
the evacuation did not notify his OIC or the IC that he
had exited by a rear balcony and was OK.
o
All
firefighters should be equipped with a radio.
•
Situational Awareness – firefighters must be
alert and attentive, situational awareness must be must
be updated constantly through observation and
communication
o
It
appears the fact that the fire was in the attic was
communicated early.
o
It
is unclear if a 360-degree evaluation of the structure
was made prior to committing units to the interior.
o
It
is unclear if the interior crews or IC was aware of the
roof construction (probably not light weight truss based
on the fact that there were “lathe and plaster walls and
ceilings”). They were obviously not aware that it was
about to collapse
o
Even though crews were operating on the top floor with a
“heavily involved” attic fire, a secondary means escape
was not provided.
o
No
one was aware that the fire had extended down and was
now blocking the stairs.
o
The
firefighter that became separated from his crew when
attempting to evacuate was aware of or discovered the
balcony as a means of escape.
•
Decision Making (Risk-Benefit Analysis) – depends
on four factors: information, experience, knowledge, and
urgency
o
In
this situation it is unclear if a 360 degree size-up was
conducted by anyone.
o
It
is unclear if anyone’s Risk-Benefit Analysis took into
account the delayed discovery, the resultant burn time
of the structural members and the potential for
collapse.
o
It
is does not appear that the IC’s or Division Chief’s
Risk-Benefit Analysis considered the sever hazard to
firefighters when they were allowed to directly enter an
unoccupied “heavily involved” attic for fire attack
(“Fire attack was underway when the roof and ceiling
system failed plummeting two firefightersto the second
floor.”).
o
A
back-up line was assigned to support the attack crew.
o
Knowing that the suppression assignment was risky, the
IC made a decision to assign a Division Chief
specifically to monitor the interior attack operations.
•
Teamwork – to accomplish a common goal a group
must work together and cooperate, and have a leader and
followers
o
The
interior crews stayed together despite the confusion
caused by an unexpected event like a collapse with
downed firefighters.
o
After the collapse Division Chief remained focused on
his assignment and did not become involved in the
firefighting or rescue work on the second floor.
o
It
appears that all members understood their place (leader,
follower) on the crew.
o
When the firefighter became separated during the
evacuation he did not notify his OIC or the IC. He was
not missed until the accountability check was conducted.
•
Task Allocation – knowing the strengths and
weakness of team members, assigning tasks accordingly
and dividing labor so no team members are overworked
o
It
appears that units were given assignments commensurate
with their equipment and training and carried out their
assignments.
o
An
RIT was assigned but could have been more proactive in
trying to prevent a Mayday situation by doing such
things as placing ground ladders to the upper floors.
o
The
second floor was not laddered and there is no indication
of ventilation efforts. It is unclear if adequate
resources were on the scene to cover all critical tasks.
•
Debrief – critiquing team and individual actions
in a productive manner to reinforce good practices,
correct bad practices to avoid mistakes in the future,
and share experience
o
There is no indication that a debrief (critique) was
conducted.
o
Every incident presents an opportunity to learn.
Critiques should be conducted after every “working”
incident, especially the near-miss situations
o
It
is important that this be done in a non threatening
atmosphere so that members feel comfortable relating
such information.
o
The
information gained through critiques is critical in
educating other firefighters, reinforcing good practices
and identifying the need for new practices or changes.
o
Lesson learned and shared from critiques and near-misses
may save another firefighters life.
o
When done properly written critiques are an excellent
way to share vital information. They should be written
in a positive manner, reinforcing what went right and
providing lessons learned, not pointing fingers or
embarrassing specific people or units.
Note: The questions posed are designed to generate
discussion and thought in the name of promoting
firefighter safety. They are not intended to pass
judgment on the actions and performance of individuals
in the reports. Firefighternearmiss.com is funded by a
grant from the U.S. Department of Homeland Security's
Assistance to Firefighters Grant program. Founding
dollars were also provided by
Fireman's Fund Insurance Company.
The project is supported by
FireFighterCloseCalls.com
in
mutual dedication to firefighter safety and survival.
|
